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Keeping Sports Safe: Physicians Should Take the Lead

William O. Roberts, MD


The image is familiar and dramatic. An elite athlete is injured, and a sports medicine physician is at his or her side while the athlete is carried from the field or arena to the sidelines and perhaps to a waiting ambulance. Thousands in the stands and millions more in front of televisions watch the physician practicing sports medicine in a most public way and are reminded that sports participation is a risky business.

Such public treatment, however, reflects only one side of sports medicine. Perhaps the heart of our practice is attempts to prevent injuries in the first place. Prevention measures, especially for young athletes, are the most effective methods of injury reduction because they preclude injury or reduce its severity.

Intervention Strategies

Primary prevention may not involve the drama of on-field treatment, but it is proactive and requires a keen eye for spotting risks and a persistent search for ways to minimize them so athletes can continue to play and compete. Primary prevention involves a continuum of strategies, from passive to active.

Passive strategies. Passive strategies do not require participant cooperation and are therefore the most reliable measures for preventing injury. Examples include break-away bases in baseball and softball, early-morning start times in summer road races, and withholding wrestlers who have herpes dermatitis from competition. One notable recent example of this was the start time change from 6:30 pm to 7 am for the men's marathon in the 1996 Summer Olympic Games in Atlanta; the change undoubtedly improved performance, prevented exertional hyperthermia, and decreased the potential for heatstroke.

Active strategies. Active primary prevention requires an athlete to cooperate or make behavior changes, and, consequently, it is not as reliable as passive interventions. Examples include educational efforts and safety advisories, such as recommendations that athletes drink more fluids during activity to maintain hydration, slow their race pace in hot conditions to prevent heat stress, or use individual water cups to prevent the spread of disease.

Blended strategies. Between these extremes are a number of strategies that blend the passive and active approaches and require degrees of athlete cooperation. The rules of the game are the fundamental primary strategy for preventing injury. They define standards of conduct for all players and allow them to expect certain responses. Strict rule enforcement is critical to safety.

A subset of blended strategies is enforced or required interventions, such as the use of protective equipment in football, helmets in bicycle races, neoprene wet suits in cool-water swim races, and weigh-ins in ultradistance races.

Recent developments in distance running, wrestling, and ice hockey suggest the benefits and occasional pitfalls of these intervention measures that have been effected largely through the efforts of physicians.

Weather-Wise Event Management

Environmental conditions can impair athletic performance and even stress athletes beyond the limits of recovery. However, there is no reason to subject athletes to extreme or even marginally dangerous conditions when other options are available. In hazardous conditions, common sense and scientific data should prompt athletes, coaches, and sports administrators to find reasonable alternatives so athletes can compete safely in their sports at peak levels.

A good example of this kind of passive prevention is the rescheduling of the 3,200-m race in the Minnesota State Tournament Track Meet. The medical staff, after caring for several collapsed runners each year following this race, suggested that it be switched from its traditional late afternoon spot in the meet to a midmorning start. The Minnesota State High School League made the change, and since then, no athletes have collapsed or required intravenous fluids to aid recovery following the race.

Wrestling With Tradition

For years wrestlers have taken extreme measures to reach a desired weight. After three college wrestlers recently died in this effort, many of us wondered, "Why do athletes have to die before rules are changed?"

Unfortunately, evidence-based science, educational programs, and common sense failed these young athletes. They continued a long tradition of unsafe weight-loss practices. This tradition should have been abandoned by the wrestling community long ago, but it was firmly rooted in the rules of college wrestling. For many years, college wrestlers weighed in 5 hours before competing, which left them time to eat and drink a fairly large amount after having starved themselves to cut weight. In the past few years, weigh-ins have occurred 24 hours beforehand, encouraging wrestlers to cut weight even more dramatically because they had more time to recuperate before the match. Now the deaths have scarred a great sport that has benefited many young athletes.

A committee of the National Collegiate Athletic Association (NCAA) recently recommended that weigh-ins occur 2 hours before the start of a tournament and 1 hour before a dual meet. Even with this change, some college wrestlers and those not governed by the NCAA will undoubtedly continue to use drastic and unsafe methods to make weight or certify at the lowest possible weight. Physicians may soon have a new opportunity to influence college wrestlers' safety: The NCAA may require that a physician or athletic trainer set the minimum safe weight for each wrestler. However, in Minnesota and Wisconsin some wrestlers have subverted a similar rule by cutting weight before the certification exam.

A better solution would be to change the rules permanently for all youth, high school, and college wrestling to require weigh-in at the mat's edge. This one change would promote wrestling at a natural, lean weight, because dehydrated, emaciated competitors would soon learn that they cannot compete. It will take tremendous courage for the wrestling community to make and enforce a safe and universally effective primary prevention strategy.

Unintended Consequences of Safety Measures

Though seemingly well-founded, safety innovations sometimes have unintended consequences that dilute their effectiveness. Ice hockey prevention strategies are a good example.

The use of hockey helmets and face shields has decreased the risk of eye loss, facial laceration, dental injury, bruises, and contusions. However, these improvements have apparently increased the risk of serious head and neck injury. The aggressive nature of the sport has been heightened by the false sense of security that added protection gives players, especially young ones.

This invincible attitude was brought home to me by a 15-year-old hockey player patient, who boasted, "I can hit anyone as hard as I want, any time I want, and it doesn't hurt me!" This player's enthusiasm for collisions might be tempered if he wore less protective gear and feared painful collisions.

The truth is, padding, helmets, and face masks do not impart invincibility. Despite national-level education programs and rule changes to prevent cervical spine injury, two more youth hockey players in my home state of Minnesota suffered neck fractures this past season. One victim, a defender making a full-speed effort to stop an opponent, ended his hockey career by sliding beneath the player and crashing head-first into the boards. The resulting quadriplegia was a high price for a 15-year-old to pay. Active education and rule enforcement strategies have not decreased the rate of hockey-related cervical spine injury in Canada, which remains constant at about 15 per year (1).

A primary prevention strategy that eliminates intentional body contact in ice hockey for juveniles may be the only solution to the neck-injury risk for these athletes.

Leaders in Prevention

My heroes in sports medicine are those who notice a risk and search for primary prevention strategies. Some examples: Thomas J. Pashby, MD, Toronto, and Paul F. Vinger, MD, Concord, Massachusetts, whose research on eye injuries in hockey led to the use of face masks; David H. Janda, MD, Ann Arbor, Michigan, whose work on sliding injuries in softball led to break-away bases; Frederick O. Mueller, PhD, Chapel Hill, North Carolina, whose studies of cervical spine injury in football prompted the ban on spearing; and Charles H. Tator, MD, PhD, Toronto, whose assessment of cervical spine injuries in hockey helped outlaw checking from behind.

Since all sports pose some risk of injury, the goal of the sports medicine physician should be to make or keep the risk as low as possible while preserving the fundamental nature of the sport. This goal is best accomplished, especially among young athletes, through primary prevention strategies that force the desired behavior or change in conditions. However, when sports are changed to increase safety, such changes tend to be viewed as radical breaks from custom and are often difficult for professionals in the sporting community to accept. Those who seek change may have to buck tradition.

Sports medicine physicians who observe trends or conduct more formal surveillance studies will be able to suggest safety-related changes, because they will be well-equipped to report their findings and advocate solutions. By doing so, they can help create safer conditions for peak athletic performance.


  1. Tator CH, Carson JD, Edmonds VE: New spinal injuries in hockey. Clin J Sports Med 1997;7(1):17-21

Dr Roberts is a family physician at MinnHealth SportsCare in White Bear Lake, Minnesota, and medical director of the Twin Cities Marathon. He is a fellow of the American College of Sports Medicine, a charter member of the American Medical Society for Sports Medicine, and an editorial board member of The Physician and Sportsmedicine. Address correspondence to William O Roberts, MD, MinnHealth SportsCare, 4786 Banning Ave, White Bear Lake, MN 55110.




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